Ensures that records are coded within 48 hours of completion of dictation, excluding weekends and holidays. |
Reviews documentation for completion and accuracy to ensure proper assignment of CPT, ICD-9, and HCPCS codes and modifiers. |
Contacts responsible physician in a professional, tactful manner, if diagnosis is not available on medical record. |
Codes diagnoses and procedures on clinical summary agree with physician's preference 100% of the time. |
Refers medical record to director, If there is a question regarding the diagnoses/codes. |
Utilizes computerized coding/abstracting equipment. |
Codes all diagnoses/procedures in accordance to ICD-9-CM coding principles and the Coding Manual. |
Logs diagnoses, procedures and other abstracting data on worksheet for abstractor to input into computer and/or inputs diagnoses, procedures and other abstracting data into computer themselves. |
Meets quality standards of having 95% of principal diagnoses and procedures appropriately and/or correctly coded. |
Maintains 99% rate of information correctly abstracted. |
Reviews coding periodicals within seven (7) days of receipt. |
Notifies director whenever work is more than 48 hours behind work deadline. |
Assists the director with state requirements and reports. |
Acts as a resource person to BMG staff and physicians for coding and may provide education regarding coding changes/issues. |
Must be familiar with all medical record and coding requirements. |
Maintains a good working relationship within the department, other departments and medical staff. |
Willing to accept additional assignments. |
Performs performance improvement functions through data collection and documentation review. |
Demonstrates the ability to deal with pressure to meet deadlines, to be accurate, and to handle constantly changing situations. |
Demonstrates the ability to deal with a variety of people, deal with stressful situations, and handle conflict. |
Professional Requirements: |
Adheres to dress code. |
Completes annual educational requirements. |
Maintains regulatory requirements. |
Wears identification while on duty. |
Maintains confidentiality at all times. |
Attends department staff meetings as required within the department. |
Reports to work on time and as scheduled; completes work in designated time. |
Represents the organization in a positive and professional manner. |
Actively participates in performance improvement and continuous quality improvement (CQI) activities. |
Coordinates efforts in meeting regulatory compliance, federal, state and local regulations and standards |
Communicates and complies with the Benefis Health System Mission, Vision and Values as well as the focus statement of the department. |
Complies with Benefis Health System Organization Policies and Procedures. |
Complies with Health and Safety Standards and Guidelines. |
